Socio Economic Inequalities: Health

Research on health inequalities is grounded in social epidemiology, which explains how people’s social circumstances affect their health (Graham, H 2007:5).

Explanatory frameworks have been presented and theories proposed in order to explain the variations in health across social class (Asthana, S & Halliday, J 2006:45). This essay will discuss and analyze the sociological theory necessary to understand social class inequalities in health within the UK. Implications for health policy and practice will also be discussed.

Discussion:

Socio-economic inequalities in health: demographic, mortality and morbidity information:

Reports outlined since the 1980’s the extent of which ill-health and death are unequally distributed among UK: The Black Report (1980), Health Divide (1988), The Acheson Report (1998), The Solid Facts, WHO (2003), The Marmot review (2010).

These documents identified a social gradient in health: socio-economic status (SES) influences health, whereby higher position equates to better health (Caspi, A & Poulton, R 2003). From here, sociology found a correlation between mortality against social position. Britton et al (1990), Rosato, M et al (1998), Reid, A & Harding, S (2000a)(2000b) Asthana, S. et al (2004) Marmot & Wilkinson, (2005) Barry & Yuill, (2008) Health Survey for England (HSE) provide information on mortality and morbidity by social class: people in class I have longest life expectancy while people in Class IV have the shortest life span; mortality is greater in Wales, Scotland, N. Ireland and N. England than in S. England; same patterns appear for IHD, stroke and cancer mortality in between social classes, but is less evident for accidents and suicide; risk of developing chronic illness in adult life is high for people with low SES; childhood mortality is more prevalent in socially disadvantaged groups;

Sociological theory: The cultural / behavioral explanation:

In this argument primary responsibility for the differential between social position and health is placed within the individual, rather than the larger society {a culture of poverty approach}(Matcha, D.A 2003:90). Explanations focus on the way individuals from different social groups lead their lives (Clarke, A 2003:122). Smoking, alcohol, diet and exercise are chosen for detailed enquiry, as they are thought to be ‘voluntary choices’ (Blaxter, M 1990:113).

Social epidemiologists identified a hard and a soft version of cultural/behavioral explanation. Both versions start by observing that health-damaging behaviors are more prevalent among the poor than the socially disadvantaged (Asthana, S & Halliday, J 2006). The hard version implies that ‘behaviors’ are ‘voluntary’, the result of individual decisions (Blaxter, M 1990) thus, the fact that people adopt unhealthy behaviors is due to ‘ignorance, recklessness or fatalism’ (Asthana, S & Halliday, J 2006:26).

The soft version suggests that rather that seeing health-related behaviors as a ’cause’ of health inequalities, they should be seen as ‘outcome’ or ‘consequences’ of differences in the material circumstances between socio-economic groups {behavior as a result of ‘culture’} (Asthana, S & Halliday, J 2006:27). For example, in Britain smoking displays a clear class-gradient: the less advantage social class, the more likely is the individual will smoke (Bartley, M. 2004:65). Townsend, in 1995 shows that 70% of single parents on low income, social housing, manual occupations, with few educational qualifications, are regular smokers. Also, in 1998, The Office for National Statistics showed that levels of smoking for men were 12% for class I and 41% in class V.

However, in sociological research focus exists on ‘behavior’ rather than ‘culture’ (Woodward et al, 1992; Lynch, Kaplan and Salonon, 1997b) because ‘reckless behavior’ is not accepted as a definition of ‘culture’ (Bartley, M. 2004:68).

Bosma, Von Mheen and Mackenbach, (1999a) (cited in Bartley, M 2004:66) suggest a ‘direct behavioral model’ in which people with low status and income are less endowed with ‘intelligence’ and ‘coping skills’ which make them unable to grasp the long-term health consequences of things that give them short-term pleasure (e.g. smoking, drinking, etc).

Regarding ‘education’ and ‘behavior’ Blaxter, 1990; Gran, (1995), Hoeymans et al., 1996 (cited in Bartley, M. 2004) find that education is correlated with health behavior: educated people have a better understanding of health. They also make better use of preventive health measures such as contraception, screening services or immunization. For example, a survey published in 2007 by Health Survey for England (HSE)” Healthy lifestyles: knowledge, attitudes and behavior” 30% men and 24% women agreed with the statement “I get confused over what’s supposed to be healthy and what isn’t”(p. 108).

Marmot et al (1981 ) that individuals from class V have high incidence of CHD due to diet being higher in sugar content than in fiber. National Food Survey (1985) shows that low-income groups purchase less vegetables, fruits or whole meal bred.

Behavioral explanations view consumption patterns as a reflection of cultural differences in the way people live their lives. Lifestyles are thought to be shaped by traditional views and socially accepted patterns of behavior. The fact that low income may constrain food choice is ignored or rejected (Clarke, A 2001: 123)

Critique and weaknesses of the cultural/ behavioral explanation

The problem with this explanation is that it separates ‘behavior’ from the social context in which it takes place and effectively blames the victim of health inequality for the poor health that they experience (Asthana, S & Halliday, J 2006:26). Instead, individual decision‑making should be seen in the context of the social structure and of the constraints that impede the behaviors of people.

In support to this, Dobson et al 1994(cited in Barry & Yuill 2006) researched forty-eight households to observe food purchasing and attitudes toward eating. They found a pattern of life under constant economic restrictions. Also, in 1991, the national Children’s Homes survey on nutrition and poverty finds that 1 child in 10 and 1 adult in 5 skip meals because of costs. Thus, it is not people failing to practice good health habits but their choice is affected by limited funds (Barry& Yuill 2006:108). Also, in an HSE survey (2007) 22% men and 20% women agree, “it costs too much”[to eat healthy] (p. 108). In 2010, The Marmot Review emphasized that insufficient funds to lead a healthy life is a significant cause of health inequalities (p. 29)

Although health-damaging behaviors are more common among low groups, these groups also lack: adequate income, decent housing and secure employment. Therefore it is hard to separate behavioral explanation (Gatrell, C.A 2003: 113) from structural/material explanation (poor housing ƒ› unhealthy life) and social selection explanation (poor health for low classƒ› unhealthy life)

Health policy response to inequalities in health linked to social class:

Advocating healthy public policies is the most important strategy we can use to act on the determinants of health. (CPHA Action Statement on Health Promotion 1996)

Up to date health policies include: The New NHS (1997); A First Class Service (1998); Choosing Health (2004); The Wanless Report (2004) Tackling Health Inequalities (2008); Darzi Report (2008); The Marmot Review (2010)

The Marmot review:

Policy objectives A-F:

· Give every child the best start in life

· Enable all children, young people and adults to maximize their capabilities and have control over their lives

· Create fair employment and good work for all

· Ensure a healthy standard living for all

· Create and develop healthy and sustainable places and communities

· Strengthen the role and impact of ill-health prevention. (UCL Research Department of Epidemiology and Public Health, 2010)

Implications for health care practice:

Important documents: “Choosing health: making healthy choices easier” (2004) and “Health Challenge England” (2006)

– people need convenience and choice in advice available to prevent ill health.

Health care practice can contribute to reducing health inequalities through:

· Assessment / use of evidence: accurate assessment of people’s health promotion needs; linking evidence of practice outcomes to broader changes

· Strategy: population specific health care strategies; getting the promotion/prevention/treatment balance right

· Communication & Collaboration: 1.collaboration with people: involving and engaging most excluded; 2.collaboration with MDT: assessing / implementing / evaluating / updating

· Training: improving training and professional development, particularly in relation to work with most disadvantaged

· Service development: being well informed about health inequality trends, impacts and intervention effectiveness

· Service access: reducing financial barriers to health care

· Resource allocation: making conscious, informed choices about priorities.

(Wiseman, J 2007)

(Choosing Health 2004)

The time for action on health and health inequalities

Health in the consumer society

Children and young people – starting on the right path

Local communities leading for health

Health as a way of life

A health-promoting NHS

Making it happen – national and local delivery

Consultation making it happen

Assessment – suitable assessment of local needs (collaborative therefore patient and public involvement / use of evidence)

Strategy

Communication – appropriateness (methods and means)

Service Needs (recruitment, training)

Resources (access, materials, skills mix {MDT?, suitable tools and interventions)

References:

Asthana, S., Gibson, A., Moon, G., Brigham, P. and Dicker, J. (2004) The demographic and social class basis of inequality in self reported morbidity: an exploration using the Health Survey for England. Epidemiology and Community Health, 58, (4), 303-307

Blaxter, M. (1990) Health and Lifestyles, London: Tavistock Payne J, Coy J, Milner P, et al. Are deprivation indicators a proxy for morbidity? A comparison of the prevalence of arthritis, depression, dyspepsia, obesity and respiritory symptoms with unemployment rates and Jarman scores. J Public Health Med 1993;16:113-14.

Dahlgren G & Whitehead M (1991). Policies and Strategies to Promote Equity in Health. Stockholm: Institute for Future Studies.Davey Smith G, Hart C, Watt G, et al. Individual social class, area-based deprivation, cardiovascular disease risk factors and mortality: the Renfrew and Paisley study. J Epidemiol Community Health 1998;52:399-405.

Drever F & Whitehead M (1997). Health Inequalities. London: The Stationary Office.

Graham, H (2007) Unequal lives: Health and Socioeconomic Inequalities, Open University Press, McGraw-Hill Education: England

Graham H (2004a). Social determinants and their unequal distribution: clarifying policy understandings. Milbank Quarterly, 82, 101-24.

Graham H (2004b). Closing the Gap: Strategies for Action to Tackle Health Inequalities. Presentation at the 1st Business Meeting of the EU Project ‘Closing the Gap’ on 27/28 October 2004, Cologne.

Lynch, J.W., G.A and Salonen, J.T (1997b) why do poor people behave poorly? Variations in adult health behaviors and psychosocial characteristics by stages of the socio-economic life course; Soc Sci Med 44, 809-19.

Marmot M & Wilkinson RG (2005). Social Determinants of Health. Oxford: Oxford University Press (2nd edition).

Williams, A. Cooke, H. May, C (1998) Sociology, Nursing and Health, Elsevier Health Sciences: London

Woodward, M., Shewry, M.C., Smith, W.C.S and Tunstall-Pedoe, H. (1992), Social status and coronary heart disease, Preventive medicine 21, 136-48.

Mackenbach JP & Bakker M (2002). Reducing Health Inequalities: a European Perspective. London: Routledge.

Williams, A. Cooke, H. May, C (1998) Sociology, Nursing and Health, Elsevier Health Sciences: London

Caspi, A & Poulton, R Personality and the socioeconomic-health gradient, Oxford Journalls online, International Journall Of Epidemiology, vol. 32, number 6, pp. 975-977, accessed online on February 27th 2009, http://ije.oxfordjournals.org/cgi/content/full/32/6/975

The Marmot Review( 2010) UCL Research Department of Epidemiology and Public Health, accessed online February 29th 2010 http://www.ucl.ac.uk/gheg/marmotreview/FairSocietyHealthyLives

Social Inequalities in Health. New Evidence and Policy Implications. J Siegrist and M Marmot (eds). Oxford University Press, 2006

Rickards L, Fox K and Roberts C (2004) Living in Britain: Results from the 2002 General Household Survey. London: The Stationery Office; Bambra C, Joyce K and Maryon-Davis A (2009) Task Group on priority public health conditions, final report. Submission to the Marmot Review

http://www.ucl.ac.uk/gheg/marmotreview/consultation/Priority_public_health_conditions_summary

Wiseman, J. Health Inequalities: Key Trends and Implications for Health Care, Presentation to Primary and Community Health, March 2n 2007